Upper GI Bleeds - Pathology and Risk Factors

Hematemesis, coffee ground emesis and melena will certainly get your attention as a prehospital provider. This is one of the hallmark signs of an upper GI bleed. By definition, to be considered "upper" the cause has to originate above (or proximal to) the ligament of Treitz (so part or all of the mouth, esophagus, stomach and duodenum are included). The causes are many and can be better understood when compartmentalized by body region. Treatments are also specific to underlying cause. Medical management, non-surgical hemostasis or surgical intervention may be necessary depending on the patients' clinical condition and history.

Esophageal origins

Esophagitis

Esophageal varices (dilated veins that can rupture and be life-threatening)

Esophageal neoplasm (cancer)

Mallory-Weiss tear

Increased vomiting from reflux, ETOH use or potentially eating disorders like bulimia

Stomach (gastric) origins

Peptic ulcer disease (most commonly caused by the bacteria H. pylori)

Portal HTN

Gastric cancer

Duodenal origins

Peptic ulcer disease - continued -- stress can cause this as well

Arteriovenous malformation (AVM) - simply put they are abnormal vessel connections

Keep in mind that any of the above can be a consequence of complication of anticoagulation as well. Getting an accurate medication history can be vital as part of your history taking in the field. Medications like warfarin, apixaban, rivaroxaban are just a few that come to mind)

Remember that the blood is coffee ground in appearance and the stool is black and tarry (melenic) because the blood (hemoglobin specifically) gets oxidized as it makes its way through the various parts of the GI tract. However, if the bleeding is brisk in nature, the patient may report hematochezia - which normally is reported as frank red stool and usually, but not always associated with the less common lower GI bleed.

From an EMS perspective we should focus on maintaining hemodynamic stability, ensuring airway patency, and proactively preventing shock/circulatory collapse. Try to ascertain a good history of present illness.

Do they abuse ETOH?

Do they have underlying liver disease?

Do they have a long history of NSAID use or anticoagulation?

What about a recent abdominal surgical history?

Could it be epistaxis?

Could it be hemoptysis? This is DIFFERENT than hematemesis (hemoptysis originates from the lower respiratory tract - lungs, bronchi, trachea)

Lastly, some progressive agencies are carrying low titer whole blood and have had great success transfusing patients in the field. Most protocols give the green light for transfusion if the following criteria are met:

Altered mental status, OR

SBP < 70 mmHg, OR HR > 110, OR, Shock Index > 1.0.

If they are > 65 years of age, the services are usually more proactive and transfuse sooner (SBP < 100 mm Hg for example)

Remember hypovolemic shock comes in many forms other than trauma and GSW. Whole blood has many applications.

March 4, 2024

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.